Human Rights-Based Approaches to Maternal Death in the U.S.

This article is part of a series published by RH Reality Check in partnership with the Center for Reproductive Rights. It is also published in recognition of International Human Rights Day, December 10th, 2010. Read more International Human Rights Day 2010 posts here.

Amnesty International released a report last spring entitled Deadly Delivery concerning the maternal health care crisis in the United States including how this crisis disproportionately affects marginalized communities. This report is part of a series of reports that we are issuing as part of our Dignity campaign which is focused on fighting poverty with human rights. The statistics are shocking; every 90 seconds a woman dies from pregnancy related causes. Although the vast majority of these deaths are in the developing world, it is also an issue in the United States which spends more on health care than any other country in the world. On November 2, I presented Amnesty International’s findings during a panel discussion at the UN.

The Universal Declaration of Human Rights says, “Every human being has the right to health, including healthcare.” Unfortunately, the human right to health care, particularly maternal health care, is not being met in the US. The problem is especially severe in marginalized communities such as women of color. Since the vast majority of maternal deaths in the United States are preventable, maternal mortality is a human rights issue. Mahmoud Fathalla, past president of the International Federation of Obstetricians and Gynecologists, once said, “Women are not dying of diseases we can’t treat. […] They are dying because societies have yet to make the decision that their lives are worth saving.”

Two to three women die each day in the US because of pregnancy-related causes. A further 34,000 more women experience “near misses” each year. Women in the US are more likely to die of complications resulting from pregnancy or childbirth than women in 49 other countries, including South Korea, Kuwait, and Bulgaria. In fact, according to recently released UN numbers, the maternal mortality rate nearly doubled between 1990 and 2008.

There are shocking inequities in maternal health in the US. Women of color, low-income women, Indigenous women, immigrant women and women with limited English proficiency all face additional risks. For example, black women are nearly four times as likely to die from pregnancy related causes as white women. In high risk pregnancies, black women are five and a half times more likely to die. The inequalities are also geographical; risk is not uniform across the 50 states. Women in DC are almost 30 times more likely to dies than women in Maine.

These inequities are a result of systemic barriers to maternal care in the US. One of the largest problems is the lack of access to care caused by discrimination, language barriers and financial troubles. Women have been turned away because they couldn’t speak English and subjected to racial stereotyping and disrespect which affected their treatment. There are also problems with shortages of medical providers, a lack of culturally appropriate care, inadequate implementation of protocols, and a severe lack of accountability.

Take, for example, Linda’s story. Linda Coale died of a blood clot a week after giving birth to her son, Ben, by c-section. The infant welcome packet included extensive information about acclimatizing pets to a new baby, but had failed to adequately alert her to warning signs of complications, despite the heightened risk due to her surgery.

One difficulty is the number of women going into pregnancy already in poor health. A lack of access to health care prior to pregnancy, can lead to unmanaged health conditions that complicate pregnancy for women and babies. Currently, one in five women of reproductive age have no health insurance – that is 13 million women. Women of color account for only one-third of all women, but they represent half of the country’s uninsured women.

Many women lack access to information about family planning and affordable contraceptive services. In reality, about half of all pregnancies in the US are unplanned. This is significant because women with unintended pregnancies are more likely to develop complications, face worse outcomes, start prenatal care late and receive inadequate prenatal care.

Pre-natal care is incredibly important because women without it are three to four times more likely to die. However, Native American women are 3 ½ times more likely and African American and Latina women are 2 ½ times more likely to have no prenatal care as white women. 21 states do not offer “presumptive eligibility,” which allows pregnant women to get temporary access to Medicaid before their paperwork is completed.

There is a very real shortage of health professionals, including maternal health care providers. There are particular shortages among providers who accept Medicaid – this scarcity being even worse among specialists. 65 million people live in medically underserved areas – primarily in inner cities and rural areas.This lack of health care providers can have deadly consequences. Trudy LaGrew was a Native American woman living on the Red Cliff reservation in Wisconsin who died of an undiagnosed heart condition following the birth of her son. Although her pregnancy was high risk, she was unable to seek care from a specialist who would have been a 2 hour drive each way.

One of the barriers to decreasing rates of maternal death in the US is the lack of national protocols for evidence-based maternal care or to prevent, recognize and treat leading causes of maternal death. Our country’s C-section rate is illustrative of this point. Amnesty International agrees Cesarean deliveries can be a life-saving intervention. However, the US c-section rate is 32%. If that seems high, it is. The World Health Organization recommends a range between 5 and 15%. C-section rates have increased every year since 1996, for all groups of women, for a total of a 53% increase. This is significant because a woman’s risk of death is over three times higher with c-sections, and c-sections carry a greater risk of a number of complications. This complicates the racially disparities because African American women have the highest rates of c-sections.

Just as important is receiving care after birth. Postpartum care in the US is inadequate, generally consisting of a single office visit with a physician around 6 weeks after birth. To help women, there also has to be better access to information about family planning and affordable contraceptive services. Women are 2 ½ times more likely to die if they become pregnant again within 6 months of giving birth.

When you look at all these barriers together, the US lack of an accountability system obviously contributes to the rise of maternal mortality. There is no nationwide requirement to separately report maternal deaths. So in other words, many maternal deaths are never identified as pregnancy related. In fact, 29 states and the District of Columbia have no review process at all

Nearly half of all maternal deaths could be prevented with better access to good quality maternal health care.From a human rights perspective, this is completely unacceptable. To reverse these trends Amnesty International is calling on the government to implement a robust and systematic response to the issue of maternal health in the US using a human rights framework. Domestically, Amnesty International recommends establishing and strengthening Maternal Mortality and Morbidity Review Boards to investigate maternal deaths and improve care and ensuring presumptive eligibility for Medicaid for pregnant women in all states. Nationally, Amnesty International recommends creating a single office within the Department of Health and Human Services to deal with improving maternal health care; allowing pregnant women to get temporary access to Medicaid before their paperwork is completed; and passing the MOMS for the 21st Century Act, which would expand care, improve diversity, and reduce shortages of maternal care providers.

Act now to improve maternal health care and end this human rights crisis!

Thanks so much for writing in such meticulous detail about the maternal health care crisis in US. I am very pleased to see you identify the problem as a human rights problem and not simply a problem with our health care system.

For years women have not received the basic human services to which citizens of this country are entitled. Women and children make up the bulk of the impoverished population. Women of childbearing age and their children utilize a large portion of our health care resources (and will continually require more as these disparities in basic care continue and expand). Women face the greatest barriers to accessing health care and women are more often denied access to care-as was outlined in your post. I could go on and on and talk about the disparity in pay for work, disparities in education and employment, but I am trying to keep to topic.

The bottom line is this. While there are many great things about the United States, we are far from a utopian society. In fact, compared to how things were even 20 years ago, we have fallen off the curve of excellence in many ways. I do believe that there is a new era dawning, however, one in which all people will have access to all the benefits and services this country has to offer. As we all know and see, there is a lot of resistence to change in this country right now-especially to change that will “equal the playing field for those marginalized citizens” of which you have spoken. Many people feel that to change and help others means that there will be less for them. But this is not the case. I truly believe that the US, or any country for that matter, is only as great as its people. We can’t ignore a growing number of our citizens (minorities and people of color) and we most certainly cannot continue not tending to the needs of half of our citizenship without it having dire consequences on our society as a whole. A cursory glance at history reveals that “empires” that tried to maintain such inequalities eventually fell at the hands of the oppressed (Rome, Russia, France, etc…) and new, more egalitarian societies emerged and continue to thrive to this day.

The US tends to turn up its nose at the Europeans and their socialized governments. While they have their faults, Europeans all have health care, lower c-section rates, paid maternity leave and lower maternal and fetal mortality rates. They also have better acces to higher education, higher numbers of college graduates and currently better scores on standardized education tests. (Asian nations still lead in education, technology and innovation and they also have nationalized health and educational systems. You do get what you pay for!)

The bottom line is that what we are currently doing isn’t working and if we don’t make changes soon, our downward spiral will have tragic consequences-not only for women, but for US citizens and its society as a whole.

darline-tunerlee

I was going to click over and see what “she” had to say, but then I thought, “Why ruin such a wonderful blog post and great mood with such hatred?”

Robin, All the best to you Welcome to our crazy world, Sebastian! Whatever you decide to do, WE wish you all the love, joy, peace, safety, health and blessings possible. To those “others” blubbbb (giant raspberry!!)

sharonmd

Thanks so much for your article discussing the very real crisis in maternity care in this country. However, the example below missed the point:

Take, for example, Linda’s story. Linda Coale died of a blood clot a week after giving birth to her son, Ben, by c-section. The infant welcome packet included extensive information about acclimatizing pets to a new baby, but had failed to adequately alert her to warning signs of complications, despite the heightened risk due to her surgery.

A lethal blood clot is unlikely to have any warning signs. Generally there is an event that leads to an immediate, unpredictable death. The real point here is not a lack of information about symptoms of blood clots (though arguably women could be given precautions to prevent clots, but I’m not sure if that would make any real differenct). The problem is that when we have so many unnecessary surgeries happening, we are guaranteed to have an increased number of complications that can follow even the safest surgeries. Most of the complications are not terribly problematic (such as constipation), and even most of those that cause significant harm are rarely life-threatening (such as wound infections). But with so many extra surgeries, we will also see an increase in those rare events that lead to maternal mortality: embolisms (blood clots), hemorrhage (excess bleeding), and some other uncommon events.

The problem is not the lack of education; it’s the sheer fact that so many extra surgeries are going on.